Managing the pain of traumatic injury.

Management of pain in the trauma patient is a complex issue requiring the ability to selectively match different injuries and patient situations with the most optimal pain management methods. Having an understanding of the various stages of trauma care helps clinicians to best support the goals of patient care while decreasing the detrimental effects of the stress response through good pain control interventions. When nurses have a good understanding of the various pain management interventions they are better able to assess the effectiveness, potential side effects, and goals of therapy. The following is a list of clinical pearls to help guide nurses to better manage the pain of traumatic injuries: Encourage your trauma team to standardize pain medications (particularly opioids). A protocol that uses a couple of opioids with varving routes of administration, onset, duration, mechanism of action, and side effects helps the team to become extremely familiar with them and better able to assess effectiveness and side effects. Frequent motor and sensory assessments are necessary in the injured-patient (especially with extremity and head injuries), and drug therapy choices must allow for a thorough baseline assessment and periodic checks to follow. Patients with multiple rib fractures or flail segments (particularly elderly patients) and no contraindications deserve serious consideration for treatment with an epidural. When using various pain management techniques, the nurse needs to be prepared to treat complications if they should arise. Airway equipment, drugs (i.e., oxygen, opioid antagonists, pressors), and resuscitation means must be immediately available. Nurses need to be extremely careful when receiving pain medication and other central nervous system depressant orders from various doctors involved in patients' care. If a pain management specialist is involved, all pain medication therapies should be supervised and ordered by that individual, particularly when spinal analgesia is employed. Nurses must be knowledgeable regarding the effects of spinal medications (local anesthetics and opioids) at varying spinal levels so as to assess therapeutic as well as untoward effects. Institute a diligent bowel protocol when using opioids. Opioid administration combined with the immobility and altered nutrition often associated with trauma can easily result in constipation, abdominal distention, and bowel obstruction. It is not uncommon for epidural blocks to need supplementation with other drug therapy, and this should not be considered a failure of the epidural. Any addition needs to be ordered and closely supervised by one primary team of doctors. Use of nonopioid drugs, if not contraindicated should be considered in all trauma patients. This is especially true for patients sustaining trauma and being discharged to home within 24 hours. They need to be educated about the pain they can expect the next day and how to judge if it is normal and expected or possibly the sign of a missed injury or developing complication (i.e., compartment svndrome infection).